The Transition and in By: Fuzhi Cheng

CASE STUDY #3-9 OF THE PROGRAM: "FOOD POLICY FOR DEVELOPING COUNTRIES: THE ROLE OF GOVERNMENT IN THE GLOBAL FOOD SYSTEM" 2007

Edited by: Per Pinstrup-Andersen ([email protected]) and Fuzhi Cheng Cornell University In collaboration with: Soren E. Frandsen, FOI, University of Copenhagen Arie Kuyvenhoven, Wagen ingen University Joachim von Braun, International Food Policy Research Institute Executive Summary Before China's economic reforms of the late 1970s, lack of institutions to coordinate and manage nutri­ the typical Chinese diet consisted primarily of grain tion interventions. Food policies, including those products and starchy roots, with few animal source designed to affect the relative prices of unhealthy foods, caloric sweeteners, or fruits and vegetables. foods, remain questionable because it is often diffi­ Since the 1980s, Chinese people have experienced cult to identify certain foods as "unhealthy". The drastic changes in their food consumption behavior coexistence of underweight, micronutrient- and nutritional status as a result of rapid economic deficient, and overweight populations further com­ development, expansion of agricultural production, plicates the situation. Given that large pockets of , , and technological poverty exist, special care must be taken to avoid improvement. These social and economic changes increasing the likelihood of underweight and have helped shift the Chinese dietary structure micronutrient deficiency among the population as a toward increased consumption of energy-dense result of policy changes to cope with overweight foods that are high in fat, particularly saturated fat, and obesity. It is increasingly important that poli­ and low in carbohydrates. Dietary changes have cies focusing on healthy diets and physical activities been accompanied by a decline in energy expendi­ will lead to optimal health outcomes. ture associated with sedentary lifestyles, motorized transportation, labor-saving devices at home and at Your assignment is to design what you would con­ work, and physically undemanding leisure activities. sider the most appropriate policy measures to address the problems identified in this case. Justify Along with the nutritional transition in China has the policy measures you select, and assess the likely come a rising epidemic of overweight and obesity consequences of these policy measures for public among adults and adolescents, as well as widespread health, nutrition, and economic development in diet-related, noncommunicable diseases (DR-NCDs] China. including cardiovascular diseases, diabetes, and certain forms of cancer. The DR-NCDs are currently the leading causes of death, and mortality Background rates are projected to increase in the future. Obe­ sity and related chronic diseases create large The Nutrition Transition1 adverse impacts on individuals, families, communi­ Before the economic reforms of the late 1970s, the ties, and the country as a whole and are China's typical Chinese diet consisted primarily of grain primary concerns. products and starchy roots, with few animal source foods, caloric sweeteners, or fruits and vegetables. Recognizing that obesity and associated diseases are According to estimates from the Food and Agri­ both individual and social problems, China has culture Organization of the United Nations [FAO], pursued a set of integrated, multisectoral, and based on the food balance sheet, cereals [such as population-based policies. The National Plan of rice and wheat], starchy roots [such as potatoes], Action for Nutrition in China serves as an over­ and pulses [such as beans and peas] provided 1,015 arching framework for setting food-based policies kilocalories [kcal] [62 percent], 295 kcal [18 related to the country's nutrition and health issues. percent], and 101 kcal [6 percent], respectively, to Specific polices range from promoting healthy diets the average daily per capita calorie supply in 1961, and lifestyles to providing incentives to healthy while meat products contributed only 30 kcal [1.8 food growers. In addition to food-based policies, percent]. Sweet foods were rarely consumed, con­ China is implementing intensive disease prevention tributing merely 22 kcal per day [1.3 percent]. An and control programs to address clinical aspects of average Chinese person had a supply of only 78.8 obesity-related diseases. kilograms [kg] of vegetables and 4.3 kg of fruits in Despite these efforts, the country still faces com­ 1961, equivalent to a daily calorie supply of 60 kcal plex food and nutrition issues that are at the core from vegetables and 6 kcal from fruits—or just 3.7 of its economic and social development. Broad- based nutrition programs are still missing owing to 1 in this analysis, "nutrition transition" refers to shifts in the lack of funding for nutritional activities and a dietary and physical activity patterns that are accom­ panied by demographic and epidemiologic changes. percent and 0.4 percent of the total calorie supply percent of calorie intake] in 1961 to 613 kcal/ per capita per day, respectively. Stimulants [such as capita/day [or 21.1 percent] in 2003. This trend tea and coffee], spices, and alcoholic beverages corresponds to a change in the share of energy combined contributed 9 kcal, or 0.6 percent, to from fat, protein, and carbohydrates (Figure 1], the average diet, and eggs and fish products con­ During the period 1964-66 to 2001-03, energy tributed 16 kcal, or 1.0 percent. This dietary from carbohydrates fell from 80 percent to 63 pattern, though severely lacking in necessary percent, while that from fat increased from 10 nutrients, had persisted in China throughout the percent to 26 percent. Notably, however, edible oil 1960s and 1970s. contributes a significant share of total fat intake in China [Popkin and Du 2003], Since the 1980s China has made remarkable progress in boosting national economic develop­ Since China is a large and diverse country, the ment and agricultural production. Meanwhile, the changes in dietary patterns have not been uniform country has witnessed dramatic changes in its across the population. They are influenced by a dietary structure. Cereals continued to be the main number of factors including regional, ethnic, source of dietary energy, providing 1,382 kcal/ cultural, income, and agricultural production differ­ capita/day in 2003, up from 1,015 kcal/capita/day ences. This information is not readily available from in 1961. Starchy roots became a less important food the food balance sheet, but household food con­ commodity, falling from an average per capita sumption and nutrition surveys can provide addi­ calorie supply of 295 kcal per day in 1961 to only tional insight into this matter. Results from two 175 kcal per day in 2003. In contrast, the per capita China Health and Nutrition Surveys conducted in calorie supply of meat products increased more 1989 and 1997 are shown in Table 1 to illustrate than 15 times from 1961 to 2003, growing from 30 differences in consumption patterns of major food kcal/capita/day to 451 kcal/capita/day. Other items for people living in urban and rural areas and foods such as vegetable oils also became important for people belonging to different income groups. sources of dietary energy intake. A number of interesting features are worth noting. The Chinese population now has a much richer, First, there was a decrease in grain consumption more diverse diet. Vegetables and fruits, for between 1989 and 1997 in both urban and rural instance, contributed some 8 percent to the areas and among all income groups (this is also true average calorie supply in 2003. Each person in for a longer period 1980-2003, not shown in the China, on average, had a supply of 271 kg of vege­ table]. Average grain consumption per capita per tables and 50 kg of fruit per year. The supply of day dropped almost 20 percent from 684 grams alcoholic beverages increased almost 23-fold—from [g] in 1989 to 557g in 1997, with rural and low- 1.2 to 27.1 kg/capita /year, although it is still much income people experiencing the most significant lower than in many developed Asian countries decreases. In addition, there appears to be a nega­ [11ASA 2005], The supply of sweeteners, such as tive relationship between income and grain intake— , nearly quadrupled to 8.2 kg/capita/year. In that is, higher income is associated with less grain 2003, people in China ate about nine times as consumption. Third, the per capita consumption of many eggs as in 1961 and the supply of fish and animal products has increased substantially, espe­ other aquatic products had increased from 5.2 to cially for high-income and urban people. For 32.1 kg/capita/year. instance, meat consumption grew by 23.1g in urban There is also a trend toward increasing reliance on areas, but just 14g in rural areas. In contrast to animal products relative to vegetal products for grain consumption, this result indicates a positive dietary energy. For example, although the Chinese relationship between income and animal food population had a higher per capita calorie supply of intake. Finally, on average, there was a decrease in cereals in 2003 than in 1961 (1,382 kcal compared fresh vegetable intake but an increase in fresh fruit with 1,015 kcal], the share of cereals in the overall intake. People in urban areas and with higher calorie supply declined from 62.1 percent to 47.5 incomes consume more fruits than those in rural percent. Meanwhile, animal products (including areas and with lower incomes. The reverse occurs meat products] rose from 51 kcal/capita/day (or 3.1 for vegetable consumption. Figure 1: Shares o f Fat, Protein > and Carbohydrates in Dietary Energy Supply, 1964—66 to 2001-03 [percentage]

□ Fat ■P rotein □ Carbohydrate

Source: F A O 2005.

Table 1: Consumption o f M ajor Food items, 1989and1997[mean intake in grams/capita /day, age 20- 452______Middle High Urban Rural Low-income -income -income Total Food 89 97 89 97 89 97 89 97 89 97 89 97 Grains 556 489 742 581 811 615 642 556 595 510 684 557 Coarse 46 25 175 54 226 68 98 43 78 30 135 46 Refined 510 465 567 527 585 546 544 513 517 479 549 511 Vegetables 309 311 409 357 436 356 360 357 335 325 377 345 Fruits 14.5 36 14 17 5.5 8 13 18 26 38 15 21.7 Meat 73.9 97 44 58 36 40 58 64 67 96 53 67.8 Poultry 10.6 16 4.1 12 4.1 7 6.6 10 7.7 20 6.1 12.7 Eggs 15.8 32 8.5 20 6 14 11 22 16 32 11 22.7 Fish 27.5 31 23 27 12 16 29 26 33 40 25 27.9 Milk 3.7 4 0.2 0.9 0.8 0.1 0.2 1.4 3.5 3.6 1.3 1.7 Plant oil 17.2 40 14 36 13 32 16 37 16 42 15 37.1 Source: Popkin and Du 2003.

Despite spatial and income differences, one trend is than that in 1961 [1,635 kcal/ capita /day].2 This clear for the Chinese population: as more energy- change has occurred just as energy expenditure for dense foods have become available, total energy intake in China has increased substantially. In 2003 2 Total energy intake in recent years has decreased the overall average dietary energy consumption of slightly from its peak level of about 2,980 kcal/ 2,910 kcai/capita/day was about 80 percent higher capita /day in 1998 [FA O 2005]. the Chinese has been on a steady decline, especially work and more leisure time. With the populariza­ in the past two decades. With rapid urbanization, tion of televisions, personal computers, and other more people have shifted away from high-energy- indoor entertainment systems [which become more consuming work activities such as farming, mining, affordable as income rises), expanded leisure time is and forestry in rural areas toward the service usually characterized by physically undemanding sector in urban areas. The acceleration of this activities. occupational shift is analyzed in detail in Du et al. [2002], Other changes are also important. For Livestock production increase and relative price example, Chinese households have a marked decrease. China's dramatic increase in animal-source increase in ownership of motorized vehicles, televi­ food consumption would not have been possible sions, and computers.3 Thus the use of labor-saving without a rapid expansion of its domestic livestock transportation devices and the rise in physically industry.5 Since 1985 China's pork output has undemanding leisure time also contribute to increased markedly, reaching almost 50 million decreased energy expenditure in the Chinese tons in 2004. China's beef sector has grown from population. an inconsequential output level in the 1980s to the third largest in the world [after the United States and Brazil). China has moved into second place Driving Forces behind the United States in total output of poultry Rapid changes in diets and lifestyle patterns are meat. Meanwhile, the relative price of livestock having a significant impact on China's nutritional products has followed a downward trend. Projec­ status. A number of forces are driving this nutri­ tions point to a further decline in future livestock tion transition in China. prices relative to cereals [Delgado et al. 1999). The combined substitution and income effect that Income growth. As a result of rapid overall eco­ results from the relative price decrease for animal- nomic growth, per capita disposable income in source food raises its consumption. China has increased substantially during the past two decades. As income grows, people are diversi­ Urbanization. In 2004 about 39 percent of the fying out of their traditional diet dominated by total population lived in China's urban areas, com­ cereals and other starchy staples. Studies have pared with 17 percent in 1975 [World Bank 2006). found that income elasticity for animal-source Urbanization has led to fundamental changes in foods in China has remained positive for all income food preferences and needs. For example, as the groups since the 1980s, which means an average opportunity cost of time spent on cooking Chinese person will always demand more of this increases, people tend to demand more foods out­ food given additional income (Popkin and Du 2003; side the home, and these foods usually contain high Du et al. 2004). This is in contrast to the demand concentrations of salt and fat. Huang and Bouis for other foods such as coarse grains for which [1996) found that in China, urbanization alone negative income elasticities might be the case.4 The accounted for an extra 5.7-9.3 kilograms in per tendency to purchase more energy-dense and capita consumption of meat and fish products animal-source foods when income rises may be annually and a decrease of 58.3-70.1 kilograms in related to people's apparently innate preferences per capita consumption of rice, once income and for dietary and fats or to habits possibly price effects had been controlled for. Since the adopted in infancy or childhood [Drewnowski 1989). share of rural population is still high [about 60 In addition to its dietary impact, income growth percent), the potential for further urbanization and can have adverse effects on labor supply, leading to rapid increases in per capita consumption of a decrease in energy expenditure. A "backward­ animal-source food remains high. In addition to bending" labor supply curve means that individuals food consumption changes, urbanization also with higher incomes may desire less burdensome brings about more physically undemanding jobs in the service sector and increased use of automated 3 According to the National Bureau of Statistics of transportation. China, for every 100 households there were 25 motor­ ized vehicles, 133 televisions, and 33 personal computers in 2004 (NBS 2005). 5 The expansion of China's livestock industry would not, 4 In economics, goods with negative income elasticities in turn, have been possible without the dramatic increase are called "inferior goods". in production of feed grains, such as soybeans and maize. Globalization. Since China initiated broad economic considered to be in the range of 18.5 to 25. A BMI reforms in the late 1970s, trade in food and food greater than 25 is defined as overweight, and a BMI products has increased substantially. The momen­ greater than 30 as obese. In China, the prevalence tum for further liberalization quickened after of overweight and obesity has been on the rise China's entry into the World Trade Organization [Table 2], The combined prevalence of overweight [WTO] at the end of 2001. In most recent years, and obesity was positively associated with income; annual imports of agricultural products have it was about twice as high in the high-income exceeded US$5 billion. Freer trade has driven down group [19.6 percent] as in the low-income group in the prices of several major food items including 1997 [10.9 percent]. The average prevalence edible oils and related products, which are impor­ increased by 50 percent in the eight-year period, tant sources of fat intake for the Chinese popula­ but in the high-income group it increased more tion. Globalization has also led to the penetration than 80 percent. of Western-style fast food outlets into China, and their popularity is stimulated by mass media pro­ According to a nutrition and health survey con­ motions and a generation of one-child families. The ducted in China in 2002, more than 200 million success of Kentucky Fried Chicken and McDonald's adults are estimated to be overweight, among in China is a good example of the effects of which more than 60 million are obese [China Daily globalization. 2004], Compared with levels in 1992, the preva­ lence of overweight and obesity has increased 39 percent and 97 percent, respectively. The overall Technological Advances. Technological factors can adult overweight and obesity rates average 22.8 lead people to expend less energy as they adopt a percent and 7.1 percent, but in urban areas the sedentary lifestyle, motorized transport, labor- rates rise to 30 percent and 12.3 percent. A con­ saving devices at home and at work, and physically servative prediction by Popkin et al. [2001] shows undemanding activities during their leisure time. that about 40 percent of the Chinese population will be overweight by 2025. The child obesity rate Obesity and Chronic Discuses has been estimated to be around 10 percent in China's recent nutrition and dietary changes have recent years, but it is projected to grow by 8 both positive and negative health consequences. percent a year. Studies show that in China up to 27 Many believe that the increased consumption of percent of urban children aged 10 to 12 are over­ animal-source products such as meat has helped weight [UNICEF 2005], alleviate protein-energy and micro­ nutrient deficiency, which used to be prevalent in The rising prevalence of overweight and obesity in some parts of the country. More important, how­ China poses a high risk for serious diet-related, ever, the shift toward more energy-dense, nutrient- noncommunicable diseases [DR-NCDs], including poor foods with high levels of sugar and saturated type 2 diabetes, gallbladder disease, cardiovascular fats, combined with reduced physical activity, has disease [hypertension, stroke, and coronary heart led to an epidemic of overweight and obesity in disease], and certain forms of cancer. These diet- China. Although human genes could play an related diseases, along with other chronic diseases, important role in determining a person's suscepti­ were projected to account for 79 percent of all bility to weight gain, the causal linkage between deaths in China in 2005 [Figure 2], Cardiovascular increased fat intake and obesity has been shown in disease is the leading cause of mortality and alone numerous longitudinal studies [see, for example, accounts for 33 percent of all deaths. According to Bray and Popkin 1998], the World Health Organization [WHO], deaths from chronic diseases will increase by 19 percent by Overweight and obesity among adults is commonly 2015. Most markedly, deaths from diabetes will assessed using the [BM1], defined increase by 50 percent [WHO 2005], as the weight in kilograms divided by the square of the height in meters [kg/m2].6 A healthy BM1 is

6 For infants and young children, the BMI is compared with a "reference population" of the same age that is known to have grown well. Table 2: Combined Prevalence o f Overweight and Obesity [BM ! <> 2 5 ) , 1989-1997[percentage] Income 1989 1991 1993 1997 Low 6.3 6.6 9.5 10.9 Middle 9.1 11.7 10.0 14.7 High 10.7 13.6 135 19.6 Average 10.3 10.6 10.9 15.4 Note: Data are for adults aged 2 0 -4 5 years and are from China Health and Nutrition Surveys in 1989,1991,1993, and 1997. Source: Du et al. 2004.

Figure 2: Projected Causes o f Death for A ll Ages, China (2005)

Injuries 11%

Source: W H O 2005.

Policy Issues Lack of Nutrition Intervention From the 1950s to the late 1970s, the Chinese gov­ such as inadequate agricultural output and poor ernment's responses to malnutrition were limited, food distribution. The strategies for national devel­ and concerns about nutrition were largely confined opment during this period were separated from to issues of and food availability, efforts to improve the population's nutritional status. Given the tremendous need to meet food responding fat intake. This reduction in consump­ demand for both domestic stability and national tion, however, could also decrease people's intake defense purposes, grain production was over­ of a wide range of other crucial dietary compo­ emphasized in some areas of the country, and nents such as protein, calcium, and iron. Even for diversified agriculture was neglected. The results fat intake itself, arguments arise about whether to were disproportionate amounts of some agricul­ reduce total fat intake or just the intake of selected tural products, shortage of others and an un­ types of fats like transfatty acids, erucic acid, and balanced dietary structure. saturated fats. Setting appropriate price policy at highly disaggregate levels remains a challenge to After economic reforms were initiated in the late policy makers, and other food policies pose similar 1970s, China began to emphasize the importance of challenges. coordinated development of agriculture, and the nutritional status of the Chinese population improved substantially. A comprehensive national The Triple Burden strategy for nutrition intervention, however, was The coexistence of energy deficiencies, nutrient missing for most of the 1980s and 1990s. This lack deficiencies, and excessive energy intake [the triple had to a certain extent offset the initial nutritional burden] in one population further complicates the gains from economic growth and agricultural issue. A policy directed at reducing overweight and adjustment. There is also a lack of funding allocated obesity must take into account those who are for nutritional activities and a lack of institutions to underweight and/or micronutrient deficient. Recent coordinate and manage nutrition interventions. studies have shown that underweight and over­ Consequently, government participation in nutri­ weight [or undernutrition and overnutrition] can tion interventions is limited, and larger roles are and do occur in close proximity at the national, often played by research institutes and civil socie­ community, and even household levels in China ties. [Doak et al. 2000]. For example, in a 1982 survey, 9.7 percent of adults aged 20-45 were under­ weight, whereas 6 percent were overweight. By The Difficulty of Implementing Food Policy 1989, the prevalence of overweight [8.9 percent] A number of food policies are considered contro­ had surpassed that of underweight [8.5 percent]. By versial because of their unintended nutritional 2002 the proportion of overweight adults reached impacts. One example is price policy. By changing nearly 22 percent, yet more than 6 percent of relative prices of different goods, price policy is adults were still suffering from underweight [Zhai often used to shift food consumption patterns to and Wang 2006].7 At the household level 28 achieve certain nutritional and health objectives. An percent of families have a least one underweight increase in the price of an "unhealthy" food [such member, 26 percent have at least one overweight as through a consumption tax] will presumably help member, and 8 percent have at least one under­ reduce its consumption. Standard economic theory weight member coexisting with one overweight says that an increase in the price of a good tends member [Doak et al. 2000], Concurrent with over­ to drive consumption away from that good [and its weight and underweight is widespread micro­ complements] and toward its substitutes. So an nutrient deficiency [primarily iron, vitamin A, increase in the price of an unhealthy food should iodine, and zinc], mainly among poor women and shift consumer demand toward a healthier food. children. For example, recent statistics show that the prevalence of iron-deficiency anemia in children Though simple in theory, price policy is hard to under five years of age is 12.3 percent in urban implement in practice. It is often difficult to iden­ areas and 26.7 percent in rural areas. This rate is tify foods as "unhealthy," and an increase in the highest among infants under six months of age, price of so-called "unhealthy" foods could reduce with a prevalence rate of 50 percent in rural areas access to their healthy components. For example, [WHO 2005], there is great controversy about the role of animal- source foods and caloric sweeteners. Guo et al. [1999] show that price increases for animal-source foods in China would have a large negative impact 7 The prevalence of underweight and overweight pre­ on their consumption and on people's cor­ school children is 7.8 percent and 8.2 percent [Zhai and Wang 2006], Given that large pockets of poverty exist where lowered or complete loss of productivity and many still suffer from undernutrition and vitamin income-earning and learning capacity. Families with and mineral deficiencies, particularly in China's obese members suffer from lower household poor, rural western regions, programs targeting the income and higher medical expenditures. reduction of overweight must also be capable of addressing underweight and micronutrient defi­ At the country level, the effect of obesity is ciency.8 Public health policies that aim to reverse equally large. Recent estimates suggest that about overnutrition and overweight by cutting the supply 2-8 percent of the total costs in devel­ or raising the price of energy-dense foods may oped countries are attributable to obesity. This have undesired consequences on underweight and figure was estimated to be 9.1 percent, or US$78.5 micronutrient-deficient people. Similarly, programs billion, in the United States in 1998 (Finkelstein et designed to address underweight and micronutrient al. 2003], These costs are direct costs of diagnosis, deficiency may alter the diet to the detriment of treatment, and , not groups vulnerable to overweight. Therefore, it is including indirect costs arising from loss of increasingly important for policies to focus on productivity. Of course, the true costs could be healthy diets and physical activities that will lead to even greater if all obesity-related conditions are optimal health outcomes in all three dimensions. included in these calculations. The exact numbers for China are not dear, but studies have shown that these costs could be very high. For example, Stakeholders Popkin et al. [2001] estimated that total hospital spending in 1998 on diet-related chronic diseases Obesity and related chronic diseases have large was US$11.74 billion, representing 1.6 percent of adverse impacts on individuals, families, communi­ gross domestic product [GDP] and 22.6 percent of ties, and the country as a whole. At the individual all hospital expenditures. The study also found that level, the health consequences of obesity range diet-related chronic diseases could have large eco­ from nonfatal, quality-of-Iife complaints such as nomic costs in terms of lost productivity due to respiratory difficulties, musculoskeletal problems, premature deaths. Specifically, the costs associated skin problems, and infertility to diseases that lead with this type of mortality were estimated to be to an increased risk of premature death, including US$3.41 billion, or 0.5 percent of GDP, even when non-insulin-dependent diabetes, gallbladder disease, a very conservative method of extrapolation was cardiovascular problems [hypertension, stroke, and used. coronary heart disease], and cancers that are hor­ mone related and associated with the large bowel. A more recent WHO study reported that China Hypertension, diabetes, and raised serum choles­ could lose US$18 billion dollars in national income terol are between two and six times more prevalent from premature deaths due to heart disease, stroke, among heavier women. Severe obesity is associated and diabetes in 2005 alone. These costs are pro­ with a 12-fold increase in mortality in 25- to 35- jected to rise dramatically in the next two decades year-olds when compared with lean individuals. as the prevalence of diet-related chronic diseases Negative attitudes toward the obese can lead to continues to increase. WHO estimates that cumula­ discrimination in many areas of life, including tively China could lose US$558 billion over the health care and employment. Moreover, the psy­ next 10 years from premature deaths due to the chological consequences of obesity can range from chronic diseases [WHO 2005], It is important to lowered self-esteem to clinical depression. Rates of note that these costs do not include loss of work anxiety and depression are three to four times output for patients who survive or for lowered higher among obese individuals. Individuals suffer­ work rates due to diet-related chronic diseases, ing from obesity and related chronic diseases face including lost productivity from persons who are debilitated and being treated as outpatients or not 8 In addition to the 26.1 million rural people living below being treated at all. It can, however, be argued that the official poverty line, undernutrition and micro­ the costs would be much higher if the losses of nutrient deficiency pose at least a moderate threat to the productivity due to morbidity and mortality were roughly twice as large low-income rural population living combined. on the brink of poverty, the urban poor [about 14.7 million], and a large portion of the 100 million people who "float" between rural and urban areas. Because obesity and associated conditions are both of hunger and food shortage, improvement of individual and social problems and have deep roots nutritional status, and prevention and control of in people's nutritional status, dietary habits, and chronic diseases. Emanating from the plan, a num­ lifestyle patterns, solving these problems requires a ber of demand-side and supply-side policies have multisectoral, multidisciplinary, and population- been implemented specifically to prevent obesity based approach. The relevant sectors include health, and related diseases. agriculture, commerce, education, sport, and trans­ portation ministries, as well as local governments. On the demand side, some initiatives have been Various stakeholders must be involved and coordi­ undertaken to raise public awareness about the nated, including individuals, households, the public importance of healthy diets and lifestyles. The most and private sectors, and nongovernmental organiza­ important of these are the Dietary Guidelines for tions [NGOs], NGOs like the China Nutrition Chinese Residents and the Balanced Diet Pagoda Society have taken a very proactive approach to proposed by the Chinese Nutrition Society [CNS], promoting healthy diets, and international organiza­ Similar to the food pyramid guidance system in the tions like WHO and the United Nations Children's United States, the Chinese dietary guidelines estab­ Fund [UNICEF] are also playing an important role. lish eight principles for developing a good diet. These principles include increasing the intake levels of fruits and vegetables and higher-fiber products Policy Options and reducing the intake of caloric sweeteners and fat. Correspondingly, the Chinese Pagoda, consist­ Policy options to help reduce overweight and ing of five levels of food intakes, recommends obesity directly involve a wide range of long-term average values for daily consumption of different strategies, including prevention, weight main­ foods based on estimated energy needs for an tenance, management of co-morbidities, and weight average healthy Chinese adult. loss. These strategies should be part of an inte­ grated, multisectoral, population-based approach Parallel to the dietary guidelines are different forms that includes environmental support for healthy of nutrition education campaigns throughout the diets and regular physical activity [WHO 2005], In country. For example, face-to-face nutrition educa­ a broader context, an appropriate and comprehen­ tion sessions have been held in a number of prov­ sive food and nutrition policy is essential, and the inces in China [Zhai et al. 2002], These educational formulation of this policy should be a joint effort activities are usually held at limited locations, how­ of many concerned agencies under the leadership ever, and are designed for a specific group of of the government. The policy should address food people, like public health workers at anti-epidemic production, food processing, marketing, food stations. Publications related to nutrition education, distribution, exports and imports, poverty allevia­ such as the dietary guidelines, are also available. But tion, and nutrition education. All government information dissemination concerning nutrition is sectors involved should integrate better nutrition limited in scale and usually unorganized. To date, into the goals of their sectoral plans and programs there have been no mass media campaigns related of development. Together with supply-side meas­ to nutrition in China [Zhai et al. 2002], ures, policies for fostering healthy food consump­ tion and lifestyle patterns should be regarded as Policies on the supply side consist primarily of essential in the government's efforts to meet the creating incentives for farmers to grow more challenge of increasing overweight and obesity. healthy foods. Cereals and legumes are known to contain important nutrients required for good At present, the National Plan of Action for Nutri­ nutrition, including carbohydrates, protein, and tion in China serves as an overarching framework even fat, as well as vitamins and minerals, including for setting food-based policies related to the coun­ calcium, folic acid, and iron. The Ministry of Agri­ try's nutrition and health issues. The plan was first culture and the Ministry of Commerce have col­ approved by the State Council in 1997. In 1998, laborated to promote the production of certain responsibility for carrying out the plan was trans­ cereals and soybeans. In 2004, the Chinese gov­ ferred to the Department of Disease Control of the ernment started to give subsidies for the purchase Chinese Ministry of Health. The plan sets out a of grain and soybean seeds that are considered broad range of long-term goals including alleviation "high quality." These products include soybeans with a high oil content, corn for industrial use, and these policy measures for public health, nutrition, wheat with high protein. In addition to seed subsi­ and economic development in China. dies, more general forms of agricultural support to crops are also available, for example, through direct payments, infrastructure, and agricultural research. Additional Readings There have also been efforts to enhance the pro­ duction of fruits and vegetables. In 2003, China Doak, C., L. Adair, M. Bentley, C. Monteiro, and B. reported that 145 million tons of fruits and 540 Popkin. 2005. The dual burden household and million tons of vegetables were produced—a 100 the nutrition transition paradox. International percent and 250 percent increase over the amount Journal o f Obesity 29:129-36. produced in 1995, respectively—and the majority of Popkin, B., and P. Gordon-Larsen. 2004. The nutri­ the fruits and vegetables are consumed domestically tion transition: Worldwide obesity dynamics [World Bank 2005], and their determinants. International Journal o f Beyond food-based policies, intensive disease pre­ Obesity 28: 52-59. vention and control programs administered by the Zhai, F., D. Fu, S. Du, K. Ge, C. Chen, and B. Ministry of Health are underway. These programs Popkin. 2002. What is China doing in policy­ seek to provide clinical assistance to address the making to push back the negative aspects of existing burden of obesity-related diseases. The the nutrition transition? Public Health National Plan for Prevention and Control of Diet- Nutrition 5: 269-73. Related Noncommunicable Diseases was issued in 1996 and involved integrated intervention activities carried out in 24 demonstration sites in 17 prov­ References inces [Zhai et al. 2002]. The National Guideline for the Prevention and Control of Hypertension was in place in 1998, the same year that National Hyper­ Bray, G., and B. Popkin. 1998. Dietary fat intake tension Day [October 8 of each year] was estab­ does affect obesity. American Journal o f Clini­ lished. cal Nutrition 68:1157-73. China Daily. 2004. Nearly 200 million Chinese are Attempts have been made to promote physical overweight. October 13, 2004. activity among the Chinese people. The govern­ http:// www.chinadailv.com.cn/english/doc/20 ment urges all residents to exercise regularly to 04-10 /13 / content 382110.htm. improve their health status, because appropriate regular daily physical activity is considered a major Delgado, C., M. Rosegrant, H. Steinfeld, S. Ehui, component in preventing chronic diseases. In major and C. Courbois. 1999. Livestock to 2020: The cities, local governments have increased the density next food revolution. Food, Agriculture, and of opportunities for physical activity, including the Environment Discussion Paper 28. recreation facilities such as parks, large squares, Washington, DC: International Food Policy recreation centers, and green spaces. Recognizing Research Institute. that patterns of physical activity acquired during Doak, G, L. Adair, C. Monteiro, and B. Popkin. childhood and adolescence are more likely to be 2000. 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